Effect of elastic bandage on postural control in subjects with chronic ankle instability: a randomised clinical trial

Modified Stabilization Test to Diagnose Chronic Syndesmotic Injuries Based on Posture Control

BACKGROUND

To propose and validate a modified noninvasive method for the diagnosis of chronic syndesmotic injuries.

METHODS

This study included 16 patients with chronic ankle instability. Herein, we propose the Modified Stabilization Test, a new measurement for use in the diagnosis of chronic syndesmotic injury, as determined by wearing a 60-kPa pneumatic brace. The test combines the center of pressure and sensory organization test to measure postural control. For comparison, we also measured the tibiofibular clear space, tibiofibular overlap, and medial clear space using anteroposterior radiograph; a line marked horizontally above the tibial plaque using computed tomography (CT) to measure the syndesmotic gap and fibular rotation angle; and magnetic resonance imaging (MRI) scans to determine the presence of the λ sign. The distance of syndesmosis was confirmed in 16 individuals through arthroscopy, and the results of the examination were used to determine the diagnostic efficacy of each index.

RESULTS

Receiver operating characteristic curve analysis revealed that the optimal cut-off value, sensitivity, and specificity of the Modified Stabilization Test for the diagnosis of chronic syndesmotic injuries were 0.80, 100%, and 87.5%, respectively. The area under the curve (AUC) of the Modified Stabilization Test was 0.906 (95% CI 0.656, 0.993; P < .001), which was superior to imaging indices such as radiography, CT, and MRI (AUC = 0.516-0.891).

CONCLUSION

We developed the Modified Stabilization Test-a noninvasive diagnostic tool for the screening of chronic syndesmotic injuries. The test showed high sensitivity and specificity for the identification of chronic syndesmotic injuries and is helpful in the identification of chronic syndesmotic injuries.

LEVEL OF EVIDENCE

Level II, diagnostic-investigating a diagnostic test.

Effects of Conservative Interventions on Static and Dynamic Balance in Individuals With Chronic Ankle Instability: A Systematic Review and Meta-analysis

OBJECTIVE

To determine which conservative interventions are effective for static and dynamic balance in patients with chronic ankle instability (CAI).

DATA SOURCES

PubMed, Cochrane Library, Web of Sciences, and CINAHL databases were searched up to March 20, 2022.

STUDY SELECTION

Randomized controlled trials investigating the effects of conservative interventions on static and/or dynamic balance in patients with CAI compared with those of different conservative interventions or controls were included.

DATA EXTRACTION

Two independent reviewers extracted the data. Certainty of the evidence was assessed using the GRADE approach.

DATA SYNTHESIS

Forty-eight studies (1906 participants) were included. Whole-body vibration training (WBVT) was significantly more effective than controls for both static (standardized mean difference, 1.13; 95% confidence interval [CI], 0.58-1.68; moderate-certainty evidence) and dynamic balance (0.56; CI, 0.24-0.88; low-certainty evidence). Balance training (BT) and joint mobilization were significantly more effective than controls for dynamic balance (0.77; CI, 0.41-1.14; and 0.75; CI, 0.35-1.14, respectively), but not for static balance (very low to low-certainty evidence). Adding other interventions to BT had no significant effect on either type of balance compared with that of BT alone (moderate to low-certainty evidence). Strength training (ST) and taping had no significant effect on either type of balance (very low- to low-certainty evidence). Multimodal interventions were significantly effective in improving dynamic balance (0.76; CI, 0.32-1.20; low-certainty evidence). Adding transcranial direct current stimulation to ST was significantly more effective for dynamic balance than ST (0.81; CI, 0.08-1.53; moderate-certainty evidence). The effects on balance were not significantly different among BT, ST, and WBVT (very low- to low-certainty evidence).

CONCLUSIONS

The significantly effective interventions reviewed may be treatment options for balance impairments associated with CAI. However, interventions should be chosen carefully, as much of the certainty of evidence is very low to low.

Nonanatomic All-Inside Arthroscopic Anterior Talofibular Ligament Repair With a High-Position Anchor versus Anatomic Repair: An Analysis Based on 3D CT

BACKGROUND

In patients with chronic ankle instability, it is important to repair the anterior talofibular ligament (ATFL) at the anatomic origin site. However, there are limited reports on the clinical outcomes according to anatomic ATFL repair.

PURPOSE

To compare the clinical outcomes after arthroscopic ATFL repair according to whether the anchor is fixed at an anatomic position.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We performed a retrospective review of consecutive patients who underwent arthroscopic ATFL repair for chronic ankle instability and were available for a minimum 2-year follow-up. The patients were divided into 3 groups according to the anchor position at the distal fibula on 3-dimensional computed tomography: anatomic arthroscopic ATFL repair (anatomic group), subanatomic arthroscopic ATFL repair (subanatomic group), and nonanatomic arthroscopic ATFL repair (nonanatomic group). The visual analog scale for pain, Foot and Ankle Outcome Score (FAOS), and Karlsson ankle functional score were measured as subjective outcomes. Posturographic analysis and radiologic evaluation using stress radiographs and axial view magnetic resonance imaging were performed as objective outcomes.

RESULTS

Of 96 patients, 16 were excluded per the exclusion criteria, and 80 were evaluated (anatomic group, n = 24; subanatomic group, n = 42; nonanatomic group, n = 14). The mean age of the patients was 34.5 years, and the mean follow-up period was 27.4 months. A between-group comparison revealed significant differences in FAOS, Karlsson score, and fall risk evaluated by posturography at the final follow-up. Post hoc analysis revealed that the anatomic group had better clinical scores on the FAOS than did the nonanatomic group in all 5 domains (all P < .017). Patients in the anatomic and subanatomic groups had better Karlsson scores and fall risk than those in the nonanatomic group (P = .004 and P = .013, respectively). In terms of objective outcomes, patients in the anatomic and subanatomic groups had better outcomes in fall risk than did those in the nonanatomic group (both P = .001). There were no differences in clinical scores and objective outcomes between the anatomic and subanatomic groups.

CONCLUSION

Nonanatomic ATFL repair showed inferior outcomes when compared with anatomic ATFL repair. When arthroscopic ATFL repair is performed, the anchor should be fixed in the anatomic position to improve prognosis.

Effect of Kinesiology Tape on Muscle Activation of Lower Extremity and Ankle Kinesthesia in Individuals With Unilateral Chronic Ankle Instability

Background: The purpose of the study was to determine the effect of kinesiology tape (KT) on lower limb muscle activation during computerized dynamic posturography (CDP) tasks and ankle kinesthesia in individuals with chronic ankle instability (CAI). Methods: Thirty-five men with CAI participated in this study. The experimental procedure followed a repeated measures design. Muscle activation of lower extremity and ankle kinesthesia of participants were measured using four taping treatments, namely, KT, athletic tape (AT), sham tape (ST), and no tape (NT) in a randomized order. Muscle activation was assessed using surface electromyography (sEMG) synchronized with CDP tests from seven lower extremity muscles of the unstable limb. Ankle kinesthesia was measured by using a threshold to detect the passive motion direction of the unstable ankle. Parameters were analyzed by using a one-way repeated measures ANOVA and followed by pairwise comparisons with a Bonferroni correction. Results: No significant difference was observed among different taping treatments for the majority of parameters during CDP. Except for condition 4 with open eyes, sway-referenced surface, and fixed surround in the sensory organization test (SOT), gastrocnemius medialis root mean square (RMS) was 28.19% lower in AT compared with NT (p = 0.021, 95% CI = 0.002-0.039), while gastrocnemius lateralis RMS was 20.25% lower in AT compared with KT (p = 0.038, 95% CI = 0.000-0.021). In forward-small sudden translation from motor control test (MCT), for peroneal longus (PL), RMS was 24.04% lower in KT compared with ST (p = 0.036, 95% CI = 0.000-0.018). In toes-down sudden rotation from adaption test (ADT), for PL, RMS was 23.41% lower in AT compared with ST (p = 0.015, 95% CI = 0.002-0.027). In addition, no significant difference was observed for a threshold to the detection of passive motion direction among different taping treatments. Conclusion: This study indicated that KT had minimal effect on the muscle activation of the unstable lower limb during static stance, self-initiated, and externally triggered perturbation tasks from CDP and ankle kinesthesia among individuals with CAI, suggesting that the benefit of KT was too small to be clinically worthwhile during application for CAI.

Additional Inferior Extensor Retinaculum Augmentation After All-Inside Arthroscopic Anterior Talofibular Ligament Repair for Chronic Ankle Instability Is Not Necessary

BACKGROUND

Although several arthroscopic surgical techniques for the treatment of chronic ankle instability (CAI) have been introduced recently, the effect of inferior extensor retinaculum (IER) augmentation remains unclear.

PURPOSE

To compare the clinical outcomes after arthroscopic anterior talofibular ligament (ATFL) repair according to whether additional IER augmentation was performed or not.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We performed a retrospective review of consecutive patients who underwent arthroscopic ATFL repair surgery for CAI between 2016 and 2018. The mean age of the patients was 35.2 years (range, 19-51 years), and the mean follow-up period was 32.6 months (range, 24-48 months). Patients were divided into 2 groups according to the surgical technique used for CAI: arthroscopic ATFL repair (group A; n = 37) and arthroscopic ATFL repair with additional IER augmentation (group R; n = 45). The pain visual analog scale, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, and the Karlsson Ankle Function Score were measured as subjective outcomes, and posturographic analysis was performed using a Tetrax device as an objective outcome. Radiologic outcome evaluations were performed preoperatively and at 2 years postoperatively using stress radiographs and axial view magnetic resonance imaging (MRI).

RESULTS

Out of 101 patients, 19 (18.5%) were excluded per the exclusion criteria, and 82 were evaluated. We identified 6 retears (7.3%) based on postoperative MRI evaluation. All patients who had ATFL retear on MRI (8.1% [3/37] in group A and 6.7% [3/45] in group R) demonstrated recurrent CAI with functional discomfort and anterior displacement >3 mm as compared with the intact contralateral ankle. All clinical scores and posturography results were improved after surgery in both groups (P < .001). However, there were no significant differences in the clinical results and radiologic findings between the groups.

CONCLUSION

The clinical and radiologic outcomes of patients with CAI improved after all-inside arthroscopic ATFL repair. However, additional IER augmentation after arthroscopic ATFL repair did not guarantee better clinical outcomes.

Ankle muscle activation during the limits of stability test in subjects with chronic ankle instability

OBJECTIVE

To study postural control and muscle activity during the limit of stability test (LOS) in subjects with chronic ankle instability.

DESIGN

Observational study.

SETTING

University laboratory.

PARTICIPANTS

10 healthy subjects were included in the control group and 10 subjects in the CAI group (age between 18 and 30 years, with history of the multiple ankle "giving way" episodes in the last six months and score ≤24 in the Cumberland Ankle Instability Tool).

MAIN OUTCOME MEASURES

A computerized dynamic posturography equipment was used for assessing the LOS. The electromyography activity of tibialis anterior (TA), soleus (SOL), medial gastrocnemius (MG) and peroneus longus (PL) was registered.

RESULTS

Subjects with CAI had a greater activation in TA to forward (p < .01), forward affected (p = .001), backward affected (p = .007) and backward directions (p < .01); in PL to forward affected (p < .01) and affected directions (p = .001); in MG to forward (p = .023) and affected directions (p < .01) and in SOL to the affected direction (p = .009). We observed restricted excursions and less directional control in subjects with CAI.

CONCLUSIONS

Subjects with CAI exhibited poorer ability to move their center of gravity within stability limits. In addition, they have an altered ankle muscle activity during LOS test toward the affected ankle joint.

Short-term and long-term effects of ankle joint taping and bandaging on balance, proprioception and vertical jump among volleyball players with chronic ankle instability

OBJECTIVE

This study hypothesized that the prolonged use of taping during athletic activities produces more significant increases in proprioception, balance, and vertical jump among volleyball players with CAI.

DESIGN

A randomized controlled study.

PARTICIPANTS

One-hundred participants with chronic ankle instability (CAI) participated in this study. Participants were distributed into 3-groups: taping group, bandaging group, and control group.

PRIMARY OUTCOME MEASURES

Proprioception (ankle range of motion absolute error), balance(Y-balance test), and vertical jump (vertical jump tester).

INTERVENTIONS

Three interventions were performed: ankle rigid taping, ankle bandaging, and placebo taping. The measurements were performed at baseline, immediately, 2-weeks and 2-months after support.

RESULTS

Immediately after supports, there were non-significant differences between all groups for proprioception, balance (P < .05). There was a significant difference between banding and control groups, and taping and control groups for the vertical jump (P < .05). After 2-weeks and 2-months, there were significant differences between bandaging and control groups, and taping and control groups for proprioception, balance, and vertical jump (P < .05). There were non-significant differences between taping and bandaging groups (P < .05) during all assessments.

CONCLUSION

This study indicated that ankle taping and bandaging immediately improve vertical jump only; while they improve proprioception, balance, and vertical jump after 2-weeks and 2-months.

Assessments of Sensorimotor Deficits Used in Randomized Clinical Trials With Individuals With Ankle Sprains and Chronic Ankle Instability: A Scoping Review

The main purpose of this scoping review was to summarize the most common tasks and outcome measures in randomized control trials (RCTs) used to assess sensorimotor function following ankle sprain and chronic ankle instability (CAI). We also aimed to summarize the description of inclusion criteria used in articles. We searched for RCTs published between 2008 and 2018 using the following databases: MEDLINE, PubMed, SPORTDiscus, and Web of Science. Eligible studies included participants of either sex who had had at least one ankle sprain with/without subsequent CAI. All articles assessed sensorimotor function. The tasks, outcome measures, and inclusion criteria were categorized, and frequencies of use in each category were calculated. Of 272 publications, 31 met the eligibility criteria. The most common task was single-limb stance (58% of 31). The most common outcome measure was the posterior-medial reach distance of the Star Excursion Balance Test (SEBT) (13 of 16 articles, 81%). Different inclusion criteria for a history of ankle sprains or CAI were used. A wide range of sensorimotor assessments and inclusion criteria was used among studies involving individuals with a history of ankle sprain with or without CAI, which could make it difficult to compare and generalize study results. This scoping review provides a baseline for planning future studies exploring outcome measures to assess sensorimotor function of individuals with a history of ankle sprain with or without CAI.

Do External Supports Improve Dynamic Balance in Patients with Chronic Ankle Instability? A Network Meta-analysis

BACKGROUND

To improve ankle stability in patients who have experienced an ankle sprain with residual symptoms of instability and/or objective joint laxity, external supports (such as taping, bracing, and orthotic insoles) are used sometimes. However, available randomized trials have disagreed on whether restraints improve balance in those individuals. In this situation, a network meta-analysis can help because it allows for comparing multiple treatments simultaneously, taking advantage not only of direct but also indirect evidence synthesis.

QUESTIONS/PURPOSES

The aim of this network meta-analysis was to assess (1) the impact of taping and orthotic devices on dynamic postural control in individuals with ankle instability and (2) the presence of a placebo effect in participants treated with sham taping and complications resulting from the administered treatments.

METHODS

We searched the PubMed, Scopus, and CENTRAL databases up to February 13, 2019 for completed studies. Randomized trials assessing the results of real and/or sham taping, wait-and-see protocols, ankle bracing, and foot orthotics for ankle instability as determined by one or more ankle sprains followed by ongoing subjective symptoms and/or mechanical laxity were included. We evaluated dynamic postural control in terms of the Star Excursion Balance Test in the posteromedial direction (SEBT-PM), which is considered the most representative of balance deficits in patients with ankle instability. Standardized mean differences were re-expressed to percentage differences in SEBT-PM, with higher scores representing possible improvement. Subsequently, those data were checked against the established minimal detectable change of 14% for this scale to make judgements on clinical importance. We also assessed the presence of a placebo effect by comparing the results of sham taping with no treatment and complications resulting from the administered treatments. Additionally, we judged the quality of trials using the Cochrane risk of bias tool and quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. A total of 22 trials met our inclusion criteria, 18 of which were deemed to be at a low risk of bias. A network of treatments consisting of 13 studies was created, and the level of evidence was judged to be high. As far as participants' allocation to treatment arms, 85 patients followed a wait-and-see protocol, 29 received placebo taping, 99 were treated with taping, 16 were treated with bracing, 27 were administered insoles, and six individuals were offered a combination of insoles with bracing. Of note, with statistical power set at 80%, a minimum of 16 patients per treatment group was required to provide sufficient statistical power and detect a SEBT-PM percentage difference of 14%.

RESULTS

A network meta-analysis did not demonstrate a benefit of taping or bracing over no treatment (percentage difference in SEBT-PM between taping and bracing versus control: -2.4 [95% CI -6 to 1.1]; p = 0.18, and -7.5 [95% CI -15.9 to 1]; p = 0.08, respectively). This was also the case for sham taping because the measurement increase failed to exceed the minimal detectable change (percentage difference in SEBT-PM between sham taping and untreated control: -1.1 [95% CI -6.9 to 4.7]; p = 0.72). Importantly, there were no reported adverse events after treatment application.

CONCLUSIONS

Evidence of moderate strength indicated that external supports of any type were no more effective than controls in improving dynamic postural control in patients with at least one ankle sprain and residual functional or mechanical deficits. Therefore, implementing those tools as a standalone treatment does not appear to be a viable strategy for the primary management of ankle instability. It is conceivable that combinations of rehabilitation and external supports could be more effective than external supports alone, and future trials should evaluate the potential of such combinations in enhancing not only clinician-reported but also patient-oriented outcomes using long-term follow-up measurements.

LEVEL OF EVIDENCE

Level I, therapeutic study.